October 2011 – Tips & Topics

When I was in high school, I attended a chapel service where the chaplain gave a brief talk I have remembered to this day. He said “every sermon is a lie.” That got my attention. “Black Bill” is what we used to call him -he always dressed in all black. Black Bill went on to explain …..whenever a person preaches a sermon he or she is emphasizing a certain point usually to the exclusion of equally valid and important counterpoints.

Take for example, he said, commonly-used proverbs (well not so commonly used these days) such as “Fools rush in where angels fear to tread”. It is a good message to convey: Be thoughtful and prudent about jumping too quickly to a conclusion. Consider all aspects before making a decision. But that statement is a “lie” if you consider “Opportunity knocks but once.” Meaning? Don’t procrastinate. Don’t be so careful about seizing a good deal as options and situations like this aren’t always readily available. You might miss out if you hesitate too long.

Or how about: “Too many cooks spoil the broth.” Meaning? Too many people working on a project can be ineffective and inefficient. But what about the opposite message in “Many hands make light work”? Doesn’t this say the more people who help, the quicker and easier the work gets done?

Every sermon is a lie.

The Opposing “Sermons”

Point:

This phenomenon played out recently in an article written by Lee Tannenbaum, M.D., a member of the American Society of Addiction Medicine (ASAM) and certified by the American Board of Addiction Medicine (ABAM). In the bi-monthly publication, Addiction Professional, Dr. Tannenbaum suggested that ASAM talks about addiction as a chronic disease of the brain, and teaches about managing addiction as a chronic relapsing medical disease. But then ASAM members and conference presenters act like a “split personality” with a “never-ending discussion about, and homage to, 12-Step programs” (like Alcoholics Anonymous and Narcotics Anonymous). Tannenbaum argues for less emphasis on non-medical treatments; less inpatient and residential rehabilitation treatment; and more evidence-based medical treatment.

Counter-point:

Stuart Gitlow, M.D., Acting President of ASAM, wrote a letter to the editor in the September/October edition of Addiction Professional. Dr. Gitlow wrote in part: “Once a patient has stopped using addictive substances, the clinician can begin treating the discomfort caused by the combination of the genetic and environmental influences – addictive disease itself…” He further went on to say: “It is this discomfort that will drive relapse unless it is properly addressed in a lifelong manner with sufficient intensity as to reduce risk. The primary modality of addressing this discomfort is via the development of emotional bonds – relationships between patient and clinician, addict and sponsor….These bonds are a key component of a standard medical model, which is based upon biologic, psychologic and sociocultural underpinnings…..it is unlikely that we will soon be able to address the disease itself in a purely biologic manner.”

TIP 1

Bridging the Point and Counter-point

When ASAM released a new definition of addiction in August 2011 (see Tips and Topics, Volume 9., No.5, www.changecompanies.net/tipsntopics/?m=201108) the first two sentences in the long definition were: “Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors.”

People like Dr. Tannenbaum could be forgiven for thinking that ASAM is much more focused on the biological aspects of addiction, especially when there is increasing emphasis in conferences on neurotransmitters and receptors, medication management and biological etiology and biomedical treatment. However…. the second sentence in the ASAM Short Definition of Addiction says: “Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations.” The psychosocial, spiritual manifestations of addiction cannot be healed by medication, brain scans, and biomedical interventions.

Dr. Gitlow spoke of the development of emotional bonds – relationships between patient and clinician, addict and sponsor, as a key component of a standard medical model. When he said “it is unlikely that we will soon be able to address the disease itself in a purely biologic manner”, I would go even further. Not only is it unlikely, I would say it does not fit the reality of addictive disease to pursue purely biologic treatment. To focus on purely biomedical approaches is futile. In addition, Dr. Gitlow’s highlighting of the importance of relationships and emotional bonds is consistent with what we know contributes most to effective outcomes in psychotherapy and addiction treatment – the quality of the therapeutic alliance.

You can read more about the importance of the therapeutic alliance: see references 4 and 5 below.

So here are summary points to bridge the point/counter-point gap: 

• Addiction is not just a brain disease. It is time to get back to a biopsychosocial understanding of addiction. It is biopsychosocial in what causes it.  It is biopsychosocial in the way addiction manifests itself and affects people and their families.  As well, treatment should be biopsychosocial and promote holistic and person-centered services which touch the physical, mental, social and spiritual aspects of people.
• We know there are genetic and biochemical origins to addiction. Google Marc A. Schuckit, M.D. as a starting place to understand these aspects of addiction. In addition, there are psychiatric and psychological underpinnings to addiction as well as public health principles which contribute to addiction– e.g., the more available a drug and the lower the price, the more widespread are the health and social costs of addiction to those drugs. That is why alcohol and nicotine are our biggest drug problems in deaths, health, welfare, criminal justice and other social personal and financial costs.
  
• Who crosses the line into addictive illness?
  This depends on an individual’s own “recipe”, as it were, of biopsychosocial factors. The 65 year old man may have no genetic predisposition or family history of addiction. He was a social drinker all of his life, but forced to retire by company policy, fills the vacuum with drinking.  Now later in life presents with an alcohol use disorder having succumbed to overwhelming psychosocial factors.  The 20 year old has a strong genetic predisposition, multiple family problems and role models for using alcohol and other drugs as a way of living. He lives in a drug “ghetto” with drugs on every corner. Now you see him in your office with already five years of heavy addiction problems.
• Because of the variation in how people develop and manifest addiction illness, no one treatment method or program is effective for all people. (See NIDA’s reference #6 below).

References:

1. Tannenbaum, Lee (2011): “ASAM’s Split Personality” Addiction Professional, Volume 9, No. 4. July/August 2011 pp. 66-71

www.addictionpro.com – search Archives for the original article.

2. Letters. Addiction Professional, Volume 9, No. 5. September/October 2011 page 8.

3. “The Definition of Addiction” Adopted April 12, 2011. American Society of Addiction Medicine Public Policy Statement. www.asam.org/DefinitionofAddiction-LongVersion.html

4. Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.”  In J. Lebow (ed.).  Handbook of Clinical Family Therapy.  New York: Wiley.

Reprinted in Psychotherapy in Australia, Vol.11 No. 4 August 2005. 

www.scottdmiller.com/uploadedFiles/documents/MakingTreatmentCountPsychOz.pdf

5. Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change”  Eds Barry L. Duncan, SScott D.Miller, Bruce E. Wampold, Mark A. Hubble.  Second Edition.  American Psychological Association, Washington, DC. pp 393-417.

6. National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research Based Guide” (Second Edition). April 2009.

TIP 1

Broaden your perspective on substance use problems and addiction illness.

We debate the best treatment methods, medications, 12-Step attendance and biomedical versus psychosocial approaches. But the people who actually come for some help (whether with an addiction medicine specialist, addiction psychiatrist or a specific addiction treatment program ) are really a tiny sliver of the estimated 20.5 million people (12 years old and above) who need, but do not receive, addiction treatment.

In the April 2011 edition of Tips and Topics, I discussed the huge unmet need for addiction treatment. (www.changecompanies.net/tipsntopics/?m=201104). The latest results of the 2010 National Survey on Drug Use and Health were just released September 2011. http://oas.samhsa.gov/nsduhlatest.htm

Here is the latest pie chart where a picture is worth a thousand words. Note the tiny sliver of 1.7% of people who felt they needed treatment and made an effort to get it.

• Most people getting antidepressants for depression get them from primary care physicians, not psychiatrists. Why? Because they show up in health centers, not mental health centers, psychiatrist and other therapists’ offices.  This is also where people with substance use problems and addiction show up.
• To positively impact addiction will require forging partnerships with primary care and health systems, not just behavioral health integration.  See more on Partnerships in the SAVVY section of April 2011 edition.

TIP 2

Balance the bio with the psychosocial-spiritual.

Most of us lean towards one side of the biopsychosocial continuum. This could be due to the influence of our formal training, our personal heath and recovery history, our family history and attitudes, and our clinical experience or lack of it. If you agree addiction is a multidimensional disorder which needs individualized treatment , then consider the following points and practices:

1. If you have a visceral negative reaction to giving medication to people in addiction recovery, it’s time to learn more about the “brain disease” aspect of addiction.

2. If you have a visceral negative reaction to 12-Step programs like AA or NA, it’s time to attend an open meeting and see for yourself.

3. If you think of medication as just “medication-assisted treatment or recovery” as if real treatment is psychosocial treatment and ideally drug-free treatment, then it’s time to reconsider medication as one of a menu of treatment options. Medication is in the menu of services along with individual, group, family sessions; cognitive behavioral therapy; motivational enhancement therapy; 12-Step facilitation therapy; multisystemic therapy etc. Jerry Shulman, an experienced addiction treatment colleague raised my awareness of the currently popular reference to “Medication Assisted Treatment or Recovery” (MAT or MAR). We don’t say medication-assisted diabetes or hypertension treatment as if the real treatment is diet, exercise and lifestyle change with medication just assisting the “real treatment”. We don’t think of antipsychotic medication for schizophrenia treatment as just an adjunct to the “real” psychosocial treatment. Medication is just medication to be used with some clients and not with others.

4. If you are holding out for the someday biomedical treatment that will find the right medication injection, medicine patch or long-acting vaccine or medical breakthrough, then it’s time to learn more about the power and necessity of social support networks and self/mutual help programs.

I relapsed!

I opened a letter recently. There was a “mug shot” photo of me behind the wheel of my rental car in Tucson, Arizona.  In the unfortunately unmistakable photo of me caught by the speed camera, it documented I was driving allegedly 57 miles per hour in a 45 mph section of the highway.

If you are a long time reader of SOUL in Tips and Topics, you will know that speeding is a theme that has come up a couple of times.
(See 2 back issues: January 2006,www.changecompanies.net/tipsntopics/?p=332 and May, 2010, www.changecompanies.net/tipsntopics/?p=1436)

Now this was late in the evening about 9:30 PM. There was hardly a car on the highway. Weather was fine and warm – no rain, snow, ice, roadway slickness – nothing. Perfectly safe to go- in my opinion- 67 mph even. Besides don’t they know I have only had 2 speeding tickets in the last five years (besides this one, that makes three in five years, but who’s counting?)

$239 – pay the fine, or if eligible, which I discovered I was, complete an internet driving school course for 4-5 hours and save $17 after driving school fees and county court fees. What a bargain…it costs me now only $222 for that measly 12 mph over the unreasonably slow 45 mph speed zone!

“They” should do something about those silly speed limits which could be safely bumped up by at least 5 mph in my opinion. Or somehow make exceptions for mostly law-abiding people like me. And “they” should definitely get rid of those sneaky speed cameras I wasn’t even warned about. How is a person to strategically break the speeding laws if “they” do sneaky things like cameras; or highway patrol people hiding out of view with speed radar detectors?

Last year I ended the May 2010 SOUL section with: “No actually I really am not going to speed anymore.”

I thought I was in good recovery. I even bought a Toyota Prius 18 months ago so I would be less tempted to speed than in my older, but zippier and speedier, VW Golf.

So here I am again a year plus later, ending this SOUL section with: “I really am going to try to not speed anymore.”  Maybe I didn’t relapse because I never was really committed to, and in, Speeding Recovery. You can’t relapse if you were never in Recovery in the first place.

“I really am going to try to not speed anymore.” Probably.

The Question:

Hi Dr. Mee-Lee:

I find this discussion interesting considering the far-reaching implications of this debate.  Here’s a stump the shrink for ya!

So is it best to limit our “definition” of alcohol dependence and our mindset of dependence as being a chronic, relapsing disease?

Curious as to your thoughts.

Warm regards

Tasa

Tasa Isaak, M.S., CMHP

Quality Management Specialist

Access Behavioral Health – a program of Lakeview Center Inc.

Office:  (850) 469-3884

www.accessbehavioralhealth.org

My Response:

Hi Tasa:

Good to hear from you.  Hope all is going well. As regards your question, I think there are positives and negatives to almost every concept and model.

Here are the advantages of seeing addiction as a chronic relapsing disease:

1. It helps the client, the healthcare professionals, the treatment system and the payment system understand that ongoing vigilance and services are necessary for many people – just as in diabetes, asthma, hypertension, depression, schizophrenic disorder etc.

2. It helps clinicians and systems treat relapse the same way as relapse in other chronic relapsing diseases. Instead of blaming the client and discharging them, they can still hold a person accountable and responsible for changing their treatment plan in a positive direction.

3. It makes the case for parity- instead of limited, unrealistic benefit packages which treat addiction as though a client can have a few Outpatient sessions or two lifetime residential treatments, and it will all be fixed.

Here are some disadvantages of seeing addiction as a chronic relapsing disease:

1. Substance use problems may not all be addiction illness. So using the designation of ”chronic and relapsing” should be based on a good evaluation of the person’s history and current function.  Care must be exercised not to lump everyone into the chronic, relapsing disease category.  Just as a woman can develop diabetes while pregnant, we know she does not necessarily have an ongoing disease of diabetes.  Same with some depression or psychoses.

2. Even if someone has a “chronic” disease, using other terminology might convey more hopefullness.  I think the United Kingdom uses “ongoing” or “continuing”.  Scott Miller likes to term it “cumulative” – as it is often an accumulation of lots of negative life consequences.

3.  As to the “relapsing” part, I say “potentially relapsing” to indicate that relapses are not inevitable. There are some people who have never relapsed; however if they do, then we try to normalize relapse and focus on responsibility to improve the recovery plan. This is to avoid the Abstinence Violation Effect where people feel depressed and ashamed of having relapsed.

Bottom line:  

I like to say:

1. For some, substance-use problems can be developmental and they are able to get their use under control - depending on age, circumstances and stage of life.  

2. For others it is an addictive illness. It can be a chronic or ongoing illness with a potential for relapse.

Hope this helps, but come back at me if not.  

All the best,

David

Thanks for reading. See you in late November.

David